University of South Florida Electronic Payment Authorization Form

Please read and carefully follow instructions.

For a Start or Change of electronic payment, all boxes must be completed; DO NOT leave any information blank.

This form will start, change or stop electronic payment for all payments received by you from the University of South Florida. This does not apply to employee salary payments

Name:

Please be sure the name on this form matches the name on the W-9 on file with the Accounts Payable department. Your electronic payment will not start if the names do not match.

Direct Deposit Action Requested:

  1. Check Start if you don’t have direct deposit and wish to.
  2. Check Change if you have direct deposit and wish to change your financial institution or just your account number or account type (Checking or Savings). Your current electronic payment is stopped when a change request is received. While the change is being processed, you will be paid by check.
  3. Check Stop if you wish to stop your direct deposit.
  4. Check Name Change Onlyif you are changing only your name to correspond to a change in your W-9. Complete the top portion of the form and sign and date it.

Account Number:

Please make sure the account number written on this form is correct. If you are not sure, PLEASE CONTACT YOUR FINANCIAL INSTITUTION.

Transit Routing Number:

This is the nine-digit number that identifies your financial institution. It is found in the bottom left-hand corner of your checks.

Special Note:

Please make sure your electronic payment has stopped before closing your account. Otherwise, the funds will be returned to the University and cause a delay before you receive your payment in the mail.

Please return completed form with a voided check attached to:

UNIVERSITY OF SOUTH FLORIDA

ATTN ACCOUNTS PAYABLE

4202 E FOWLER AVE ALN147

TAMPA FL 33620

Or Email to

Tax Identification Number or Social Security Number
______
Legal Name
Address
City
State / Zip
Telephone / Fax
Direct Deposit
Action Requested
(Check Only One) / (1)Start…………………………
(2)Change………………………
(3)Stop…………………………
(4)Name Change Only…………
Account Type
(Check Only One) / (1)Checking……………………
(2)Savings……………………..
Your account number – Start at left and leave unused spaces blank
______
Please make sure the account number written on this form is correct. If you are not sure, PLEASE CONTACT YOUR FINANCIAL INSTITUTION.
Name of your Financial Institution / Transit Routing Number of Your Financial Institution
______
This is the nine-digit number that identifies your financial institution. It is found in the bottom left-hand corner of your checks.
Telephone Number of Your Financial Institution
(______) ______- ______
Signature / Date

I hereby authorize and request the University of South Florida to initiate credit entries and if necessary, a debit entry in accordance with NACHA rules reversing a credit entry made in error, to my account at the financial institution named. This electronic payment is to remain in effect until withdrawn by: (a) written notification to the University; (b) death or legal incapacity; (c) the financial institution or (d) the University.

Effective September 18, 2009, the Office of Foreign Assets Control in support of U.S.C, Title 50 of the War and National Defense, requires that any payment that is being fully transferred to a foreign financial institution must immediately notify the intuition that is making the payment (University of South Florida). By submission of this request, I attest that (1) the full amount of my direct deposit is not being forwarded to a bank in another country; and (2) if at any point I establish a standing order for my Receiving bank to forward the full direct deposit to a bank in another country,I will immediately inform the University of South Florida at .

Signature above and submission of this form indicates agreement with these terms.